A patient is admitted with a 2-month history of fatigue, SOB, pallor, and dizziness. The patient is diagnosed with idiopathic autoimmune haemolytic anemia. On reviewing the laboratory results, the nurse notes which of the following that confirms this diagnosis?

Correct Answer: A

Rationale: In patients with idiopathic autoimmune hemolytic anemia, the immune system mistakenly targets and destroys its own red blood cells (RBCs). When the red blood cells are destroyed, they can break apart, leading to the presence of fragmented RBCs, also known as schistocytes or red cell fragments, in the peripheral blood. The presence of RBC fragments is a characteristic finding in this type of hemolytic anemia and helps confirm the diagnosis.

Correct Answer: B

Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.

Correct Answer: C

Rationale: Increasing the oxygen flow rate from 1L to 7L per minute without a healthcare provider's order is not safe for the client. High-flow oxygen can lead to oxygen toxicity, absorption atelectasis, and can reduce the respiratory drive in patients with COPD. The nurse's initial action should be to notify the physician about the change in oxygen delivery and the client's condition. The physician should reevaluate the client's oxygen requirements and provide appropriate orders based on the clinical assessment. It is crucial to follow evidence-based guidelines and healthcare provider orders for oxygen administration to ensure patient safety and optimal outcomes.

Correct Answer: D

Rationale: Rubella is a common childhood communicable disease that can cause severe defects in the fetus when a pregnant woman contracts the infection, leading to congenital rubella syndrome. This syndrome can result in various abnormalities in the developing fetus, such as hearing loss, vision problems, heart defects, and intellectual disabilities. Rubella is particularly dangerous when contracted during the first trimester of pregnancy, leading to a higher risk of complications for the unborn child. Therefore, Rubella is a significant public health concern due to its potential impact on fetal development and the importance of vaccination to prevent its spread.

Correct Answer: B

Rationale: Playing in sand at the park can increase the risk of lead poisoning in children because sand can be contaminated with lead particles from various sources such as old paint, industrial pollution, or leaded gasoline residues. When children play in sand, they may accidentally ingest the contaminated particles while handling or playing with the sand. This ingestion can lead to lead poisoning, as even small amounts of lead can be harmful to children's health. Therefore, playing in sand at the park poses a higher risk of lead exposure compared to the other activities listed.